[FIRST UNION]
VARIABLE LIFE APPLICATION
ALLMERICA FINANCIAL
[LOGO] ALLMERICA LIFE INSURANCE AND 440 Lincoln Street
FINANCIAL-Registered Trademark- ANNUITY COMPANY Worcester, MA 01653
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IF OIR PLEASE COMPLETE SUPPLEMENTAL APPLICATION.
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1 INSURED The person upon whose life this insurance coverage is proposed.
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First Name Middle Last
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Street Address Years at this Address
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City State Zip
( )
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Daytime Telephone Number
M/ D/ Y/
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Date of Birth State of Birth
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Social Security Number Sex
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Driver's License Number State
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2 PAYMENT The monetary contribution to the policy.
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CHECK ONE:
[ / / I have enclosed a check for my initial payment of $____________
[(100 minimum)]and have received a temporary insurance agreement.
(Please make check payable to Allmerica Financial Life Insurance and
Annuity Company)]
[ / / My initial payment will be transferred from another insurance company.
Approximate amount $________________________
Name of transferring company___________________________
My Transfer of Assets form is attached. Yes / /
My present contract has a loan that I wish to carry over to the
new contract Yes / / No / /
Loan carry over amount $ ____________. ]
[2a I WANT TO MAKE FUTURE PAYMENTS OF $___________:
/ /Annually / /Semi-Annually / /Quarterly / /Monthly
(I have included a voided check and Bank Drafting Form.)]
[2b PAYMENT REMINDER NOTICES WILL BE SENT TO THE POLICYOWNER UNLESS SPECIFIED
OTHERWISE HERE:
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Name
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Street Address
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City State Zip
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3 POLICYOWNER The person or entity exercising the policy's contractual rights.
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THE POLICYOWNER WILL BE THE INSURED UNLESS SPECIFIED HERE:
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Name
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Street Address
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City State Zip
Social Security or Tax I.D. Number
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Trust Date M/ D/ Y/ (if Trust owned)
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4 ALLOCATION How I want my payments allocated.
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Complete Section 4a. Future payments will be allocated according
to this selection unless changed by me.
4a / /ALLOCATE MY PAYMENT AS FOLLOWS: Use whole percentages.
YOUR TOTAL ALLOCATION MUST EQUAL 100%.
[ ____% AIM V.I. Cap. App. ____% Fed Am Ldrs Fnd II
____% AIM V.I. Value ____% Fed High Inc Bnd II
____% AIT Money Market ____% Fed Prime Mon Fnd II
____% Alger Am. Growth ____% Templeton Int'l Eqty
____% Alger Am. Sm. Cap. ____% Templeton Glbl Asst
____% Alger Am. Lv. Allcp. ____% MFS Gr. w/ Income
____% Dreyfus Cap. App. ____% MFS Utilities
____% Dreyfus Qual. Bond ____% Oppenheimer Main St. Growth
& Income
____% Dreyfus Soc. Resp. Growth
____% Oppenheimer Small Cap Growth/VA
____% Evergrn VA Eqty Indx
____% Oppenheimer Strategic Bon/VA
____% Evergrn VA Fund
____% Fixed Account
____% Evergrn VA Glbl Ldrs
____% Evergrn VA Sm Cp Vl 100% TOTAL ]
Deductions of all charges will be made pro rata according to the value of
each account and the Fixed Account unless otherwise specified in the
"Remarks" section of the application.
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4b AUTOMATIC ACCOUNT REBALANCING
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/ / I elect Automatic Account Rebalancing among the variable accounts to the
allocation specified in Section 4a of the main application.
/ / Month / /Quarterly / /Semi-Annually / /Annually
11365 FUIT PAGE 1
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4C DOLLAR COST AVERAGING
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Select one account from which to transfer money. Be sure you have money
allocated to this account in Section 4a.
Transfer $____________________ [($100 minimum)]
EVERY: / / Month / / Quarter / / 6 Months / / 12 Months
FROM: [/ / Fixed Account / / Allmerica Money Market Fund]
[THIS ACCOUNT CANNOT BE SELECTED IN THE ALLOCATION BELOW.]
[TO:
____% AIM V.I. Cap. App. ____% Fed Am Ldrs Fnd II
____% AIM V.I. Value ____% Fed High Inc Bnd II
____% AIT Money Market ____% Fed Prime Mon Fnd II
____% Alger Am. Growth ____% Templeton Int'l Eqty
____% Alger Am. Sm. Cap. ____% Templeton Glbl Asst
____% Alger Am. Lv. Allcp. ____% MFS Gr. w/ Income
____% Dreyfus Cap. App. ____% MFS Utilities
____% Dreyfus Qual. Bond ____% Oppenheimer Main St. Growth & Income
____% Dreyfus Soc. Resp. ____% Oppenheimer Small Cap Growth/VA
Growth ____% Oppenheimer Strategic Bon/VA
____% Evergrn VA Eqty Indx ____% Fixed Account
____% Evergrn VA Fund
____% Evergrn VA Glbl Ldrs
____% Evergrn VA Sm Cp Vl 100% TOTAL ]
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5 INSURANCE
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5a I WANT $_______________ IN LIFE INSURANCE COVERAGE.
5b I WANT INSURANCE COVERAGE TO BE: (Choose one)
/ / Option 1 Level - Insurance coverage remains constant.
/ / Option 2 Adjustable - Insurance coverage changes with
the value of your policy
/ / Option 3 Level - Cash Value Accumulation Test
5c I WANT THE FOLLOWING ADDITIONAL INSURANCE BENEFITS:
[/ / Waiver of payment upon disability
/ / Other Insured Rider (Complete Supplementary Application)
/ / Guaranteed Death Benefit Rider]
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6 BENEFICIARY
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The Primary Beneficiary is the person or entity who will receive the policy
proceeds. The Contingent Beneficiary is the person or entity who will receive
the policy proceeds should the Primary Beneficiary not survive the insured.
_____________________________________________________________________________
Name of Primary Beneficiary Relationship to Insured
_____________________________________________________________________________
Name of Contingent Beneficiary Relationship to Insured
If the beneficiary is a trust, please specify trust date.
M/_______ D/_______ Y/_______
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7 REPLACEMENT OF OTHER CONTRACTS
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WILL THE PROPOSED POLICY REPLACE ANY EXISTING ANNUITY OR LIFE INSURANCE
CONTRACT?
/ / Yes / / No
If yes, list company name and policy number.
_____________________________________________________________________________
_____________________________________________________________________________
Total life insurance in force $_______________.
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8 INFORMATION ABOUT THE INSURED
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8a I HAVE HAD AN ILLNESS OR INJURY DURING THE PAST SIX MONTHS THAT HAS
PREVENTED ME FROM WORKING FIVE CONSECUTIVE DAYS.
/ / Yes / / No If yes, please explain:
__________________________________________________________________________
__________________________________________________________________________
8b PLEASE PROVIDE THE NAME OF LAST PHYSICIAN CONSULTED, DATE AND REASON FOR
CONSULTATION.
__________________________________________________________________________
__________________________________________________________________________
8c DURING THE PAST THREE YEARS I HAD A MOTOR VEHICLE LICENSE SUSPENDED OR
REVOKED OR WAS CONVICTED OF EITHER DRIVING WHILE INTOXICATED OR OF MORE
THAN ONE MOVING VIOLATION.
/ / Yes / / No If yes, please explain:
__________________________________________________________________________
__________________________________________________________________________
8d DURING THE PAST TWO YEARS I HAVE PARTICIPATED IN OR I INTEND TO
PARTICIPATE IN:
/ / Scuba diving / / Parachuting / / Motor racing
/ / Hang gliding or similar flying activity
__________________________________________________________________________
__________________________________________________________________________
8e DURING THE PAST TWO YEARS I HAVE FLOWN AS OR I INTEND TO FLY AS A TRAINEE,
PILOT OR CREW MEMBER.
/ / Yes / / No
8f DURING THE PAST 24 MONTHS, I HAVE USED TOBACCO IN ANY FORM.
/ / Yes / /No
8g I CURRENTLY USE:
/ / Cigars / / Pipe / / Chewing tobacco / / Cigarettes
/ / Other tobacco product
(Please specify)______________________________
8h I WILL BE TRAVELING OUTSIDE OF THE UNITED STATES OR CANADA IN THE NEXT SIX
MONTHS:
/ / Yes / / No, If yes, please indicate country:
__________________________________________________________________________
[8i CURRENT EMPLOYMENT.
Name of Employer ___________________________________
Occupation and Responsibilities _______________________
_________________________________________________________________________]
[8j INCOME.
My annual earned income is $__________________
My annual unearned income is $__________________
My net worth is $__________________]
11365 FUIT PAGE 2
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9 TELEPHONE ACCESS
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Unless I did not accept the Telephone Access privilege, I understand that
Allmerica Financial Life Insurance and Annuity Company is authorized to honor
telephone requests by me, or by individuals authorized by me, to transfer
account values among sub-accounts and to change the allocation of my future
payments. I also understand that the withdrawal of funds from my account
cannot be transacted by telephone or fax instructions.
/ / I do not accept this Telephone Access privilege.
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[10 REMARKS ]
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ACKNOWLEDGMENTS AND SIGNATURES
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NOTICE TO ARKANSAS/NEW JERSEY/OHIO RESIDENTS ONLY:
"Any person who includes any false or misleading information on an
application for an insurance policy/certificate is subject to criminal and
civil penalties."
NOTICE TO COLORADO/KENTUCKY/MAINE/NEW MEXICO/ PENNSYLVANIA/WASHINGTON, D.C.
RESIDENTS ONLY: "Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals
for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties."
NOTICE TO FLORIDA RESIDENTS ONLY: "Any person who knowingly and with intent
to injure, defraud, or deceive any insurer files a statement of claim or an
application containing false, incomplete, or misleading information is guilty
of a felony of the third degree."
THIS VARIABLE LIFE POLICY IS NOT: A BANK DEPOSIT OR OBLIGATION; FEDERALLY
INSURED; ENDORSED BY ANY BANK OR GOVERNMENT AGENCY.
[GRAPHIC] [GRAPHIC]
I acknowledge receipt of current Prospectuses describing the [flexible
premium variable life insurance policy] I am applying for, and the underlying
Funds.
I UNDERSTAND THAT ANY DEATH BENEFITS IN EXCESS OF THE FACE AMOUNT AND ANY
POLICY VALUE OF THE [FLEXIBLE PREMIUM VARIABLE LIFE INSURANCE POLICY] APPLIED
FOR, MAY INCREASE OR DECREASE TO REFLECT THE INVESTMENT EXPERIENCE OF THE
SUB-ACCOUNTS OF THE VARIABLE ACCOUNT. THE POLICY VALUE ALLOCATED TO THE FIXED
ACCOUNT WILL ACCUMULATE INTEREST AT A RATE SET BY THE COMPANY WHICH WILL NOT
BE LESS THAN THE MINIMUM GUARANTEED RATE OF [4%] ANNUALLY. THERE IS NO
GUARANTEED MINIMUM POLICY VALUE. THE POLICY VALUE MAY DECREASE TO THE POINT
WHERE THE POLICY WILL LAPSE AND PROVIDE NO FURTHER DEATH BENEFIT WITHOUT
ADDITIONAL PREMIUM PAYMENTS.
It is agreed that: (1) The application consists of this application form, the
medical questionnaire and the supplemental application to apply for insurance
on family members, if it applies; (2) The representations are true and
complete to the best of my knowledge and belief; (3) No liability exists and
the insurance applied for will not take effect until the policy is delivered
and the premium is paid during the lifetime of the proposed insured(s) and
then only if the proposed insured(s) has (have) not consulted or been treated
by any physician or practitioner of any healing art nor had any tests listed
in the application since its completion; but, if the premium is paid prior to
delivery of the policy and a temporary insurance agreement is delivered by
the representative, insurance will be effective subject to terms of the
temporary insurance agreement; and (4) No registered representative or
broker is authorized to amend, alter, or modify the terms of this agreement.
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Signature of Insured Date
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Signature of Owners (if other than Insured) Date
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Signed at City State
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Official Title/Capacity
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FOR REGISTERED REPRESENTATIVE USE ONLY
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Does the policy applied for replace an existing annuity or life insurance
policy?
/ / Yes / / No
If yes, attach replacement forms as required.
As Registered Representative, I certify witnessing the signature of the
applicant and that the information in this application has been accurately
recorded, to the best of my knowledge and belief.
Based on the information furnished by the Owner or Insured in this
application, I certify that I have reasonable grounds for believing the
purchase of the policy applied for is suitable for the Owner. I further
certify that the Prospectuses were delivered and that no written sales
materials other than those furnished or approved by the Company were used.
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Signature of Registered Representative Date
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Print Name of Registered Representative TR Code/Reg Rep #
( ) ( )
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Telephone FAX
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Name of Broker/Dealer Branch #
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Branch Office Street Address
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City State Zip
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FOR HOME OFFICE USE ONLY
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11365 FUIT PAGE 3
FIRST UNION
VARIABLE LIFE APPLICATION
ALLMERICA FINANCIAL
[LOGO] ALLMERICA LIFE INSURANCE AND 440 Lincoln Street
FINANCIAL-Registered Trademark- ANNUITY COMPANY Worcester, MA 01653
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APPLICATION FOR SIMPLIFIED UNDERWRITING
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PROPOSED INSURED NAME: Sex: / / Male / / Female
Address: Date of Birth:
State of Birth:
Telephone No.: Proposed Insured S.S. No.:
PROPOSED OWNER NAME: Proposed Owner S.S. No.:
Address:
PRIMARY BENEFICIARY: Relationship to Insured:
CONTINGENT BENEFICIARY: Relationship to Insured:
INSURANCE AMOUNT APPLIED FOR: $
INSURANCE COVERAGE OPTION: / /Option 1 Level--Coverage remains constant
/ /Option 2 Adjustable--Coverage changes with the
value of policy
/ /Option 3 Level--Cash Value Accumulation Test
REPLACEMENT: / /Yes / /No Will the proposed policy replace any existing
annuity or life insurance contract?
(a) Current amount of life insurance in effect: $
(b) Company Name: (c) Policy No.:
TELEPHONE ACCESS: / /Accept / /Decline
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GIVE DETAILS TO ALL YES ANSWERS IN REMARKS. INCLUDE ALL DATES AND DIAGNOSES.
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1. Has the proposed insured within the last two years or does the proposed
insured in the future intend to:
/ /Yes / /No (a) fly as a pilot, student or crew member in any type of
aircraft?
/ /Yes / /No (b) engage in underwater diving, parachuting, hang gliding,
auto, boat or motor cycle racing?
/ /Yes / /No (c) travel or reside outside of the United States or Canada?
2. Has the proposed insured ever had or been advised to receive treatment for:
/ /Yes / /No (a) heart trouble, high blood pressure, diabetes, cancer,
tumor, epilepsy, asthma, emphysema or any disorder of
the blood vessels?
/ /Yes / /No (b) disease or disorder of the stomach, intestine, liver,
lungs, kidneys, brain, prostate or reproductive organs?
/ /Yes / /No (c) alcohol or drug abuse or any mental or nervous
condition?
3. / /Yes / /No Has the proposed insured ever tested positive on an Acquired
Immune Deficiency Syndrome (AIDS) related test?
4. / /Yes / /No Has the proposed insured used tobacco in any form in the
past 24 months?
5. / /Yes / /No For reasons not already provided, in the last 12 months has
the proposed insured received or been advised to receive, or
in the future anticipate receiving, any medical treatment,
medical testing, hospitalization or surgery?
6. / /Yes / /No In the last 12 months, has the proposed insured used any
prescription drugs?
REMARKS:
Amount paid with this application: $ 1035 Exchange/Transfer of Assets / /Yes / /No
Future payments of $ Paid: / /Annually / /Semi-Annually / /Quarterly / /Monthly
ALLOCATION OF INITIAL PAYMENT: DOLLAR COST AVERAGING: / /Yes / /No
Source Account:
Dollar Amount:
AIM V.I. Cap. App. % %
AIM V.I. Value % %
AIT Money Market % %
Alger Am. Growth % %
Alger Am. Sm. Cap. % %
Alger Am. Lv. Allcp. % %
Dreyfus Cap. App. % %
Dreyfus Qual. Bond % %
Dreyfus Soc. Resp. Growth % %
Evergrn VA Eqty Indx % %
Evergrn VA Fund % %
Evergrn VA Glbl Ldrs % %
Evergrn VA Sm Cp VI % %
Fed Am Ldrs Fnd II % %
Fed High Inc Bnd II % %
Fed Prime Mon Fnd II % %
Templeton Int'l Eqty % %
Templeton Glbl Asst % %
MFS Gr. w/ Income % %
MFS Utilities % %
Oppenheimer Main St. Growth & Income % %
Oppenheimer Small Cap Growth/VA % %
Oppenheimer Strategic Bon/VA % %
Fixed Account % %
100% TOTAL
DOLLAR COST AVERAGING FREQUENCY: / /Monthly / /Quarterly / /Semi-Annually / /Annually
AUTOMATIC ACCOUNT REBALANCING: / /Yes / /No If Yes: / /Monthly / /Quarterly / /Semi-Annually / /Annually
* Future payments will be allocated in accordance with the allocation of the initial payment unless otherwise specified.
* Deductions of all charges will be made pro rata according to the value of each account and the Fixed Account.
White - Allmerica Yellow - FUIG Pink - Agent Blue - Customer
11367
ACKNOWLEDGMENTS AND SIGNATURES
NOTICE TO ARKANSAS/NEW JERSEY/OHIO RESIDENTS ONLY: "Any person who includes any
false or misleading information on an application for an insurance
policy/certificate is subject to criminal and civil penalties."
NOTICE TO COLORADO/KENTUCKY/MAINE/NEW MEXICO/PENNSYLVANIA/WASHINGTON D.C.
RESIDENTS ONLY: "Any person should knowingly and with intent to defraud any
insurance company or other person files an application for insurance or conceals
for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties."
NOTICE TO FLORIDA RESIDENTS ONLY: "Any person who knowingly and with intent to
injure, defraud, or deceive any insurer files a statement of claim or an
application containing false, incomplete, or misleading information is guilty of
a felony of the third degree."
THIS LIFE POLICY IS NOT: A BANK DEPOSIT OR OBLIGATION; FEDERALLY INSURED;
ENDORSED BY ANY BANK OR GOVERNMENTAL AGENCY.
TELEPHONE ACCESS PRIVILEGE: If I accepted the telephone access privilege, I
understand that Allmerica Financial Life Insurance and Annuity Company is
authorized to honor telephone requests by me, or by individuals authorized by
me, to transfer account values among sub-accounts and to change the allocation
of my future payments. I also understand that the withdrawal of funds from my
policy cannot be transacted by telephone or fax instructions.
I acknowledge receipt of current Prospectus describing the ___________ policy
I am applying for, and the underlying Funds.
I understand that any death benefits in excess of the face amount and any
policy value of the [flexible premium variable life insurance policy] applied
for, may increase or decrease to reflect the investment experience of the
sub-accounts of the variable account. The policy value allocated to the Fixed
Account will accumulate interest at a rate set by the Company which will not
be less than the minimum guaranteed rate of 4% annually. There is no
guaranteed minimum policy value. The policy value may decrease to the point
where the policy will lapse and provide no further death benefit without
additional premium payments.
It is agreed that: (1) The application consists only of this application form;
(2) the representations are true and complete to the best of my knowledge and
belief; (3) No liability exists and the insurance applied for will not take
effect until the policy is delivered and the premium is paid during the lifetime
of the proposed insured and then only if proposed insured has not consulted or
been treated by any physician or practitioner of any healing art nor had any
test listed in the application since its completion; but, if the premium is paid
prior to the delivery of the policy and a temporary life insurance agreement is
delivered by the representative, insurance will be effective subject to the
terms of the temporary life insurance agreement; and (4) No registered
representative or broker is authorized to amend, alter or modify the terms of
this agreement.
Signed at Date:
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Signature of Proposed Insured
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Owner (if other than Proposed Insured)
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REPLACEMENT AND CERTIFICATION
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REPORT BY AGENCY OFFICE
Agent Code #
TO THE BEST OF YOUR KNOWLEDGE IS A REPLACEMENT INVOLVED? / / Yes / / No
As a Registered Representative, I certify witnessing the signature of the
applicant and that the questions on this application have been asked, answered
and accurately recorded, to the best of my knowledge and belief. Based on the
information furnished by the Owner or Insured in this application, I certify
that I have reasonable grounds for believing the purchase of the policy applied
for is suitable for the Owner. I further certify that the Prospectuses were
delivered and that no written sales materials other than those furnished and
approved by the Company were used.
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Signature of Registered Representative Date
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Print Name
White - Allmerica Yellow - FUIG Pink - Agent Blue - Customer
11367